Faculty of Medicine - Community Health Sciences The cost and cost-effectiveness of electronic discharge communication tools A Systematic Review Presenter: Laura Sevick, BSc, MSc Candidate Co-authors: Rosmin Esmail, Karen Tang, Diane Lorenzetti, Paul Ronskley, Matt James, Maria Santana, William Ghali, Fiona Clement April 11, 2016
Nothing to disclose Conflicts of Interest
Background Transition between acute and community care is a vulnerable period in health care delivery Incidence of post discharge adverse events between 19 and 23% Vulnerability of this period has been attributed to factors all related to the miscommunication between in-hospital and community-based physicians
Background Traditional discharge Discharge summary is prepared by physician either by hand or using a dictation tool Letter is signed by physician Sent to family doctor using fax or mail systems No controls for legibility, completeness or timeliness
Background Electronic Discharge Communication Tools (EDCTs) are one potential approach to narrowing this communication gap Two common features: (1) auto-population; (2) electronic transmission Provide immediate link Interfaces can be designed
Background Recent systematic review by Motamedi et al examined the efficacy of EDCTs 12 published studies in final inclusion Varied in terms of study design, study quality, and outcome reported Cost-effectiveness not considered/reported Bottom line: support of implementing EDCTs; uncertain if widespread implementation would be beneficial
Background ehealth initiatives have been identified as critical components of high performing systems Potential high impacts for end-users (patients), healthcare professionals, and data analysts
Alberta deputy health minister recently announced plans to create single electronic health information system to connect acute care physicians with primary care physicians (5) Background
Background ehealth initiatives are expensive: Initial cost estimate of electronic health records in Canada - $10 Billion One consulting agency suggested number as high as $98 Billion
Research Question What is the cost and cost-effectiveness of EDCTs?
Study Design Systematic review of relevant health economic literature
Research Question PICOD Population Pediatric and adult patients discharged* from one care provider to another Intervention Electronic discharge communications defined as (4): Automatic population of a discharge document by computer databases (apps included) Transmission of discharge information via computer technology Computer technology providing a platform for dynamic discharge communication Comparator Outcome Design No comparison including cost-analysis (no comparator) Traditional economic evaluation and cost-analysis outcomes (ICER, cost per QALY) Economic evaluations (RCT, modelling, simulation) and cost analyses *Discharge is defined as completion of care with one provider and transitioning care to another provider
Search Strategy Electronic databases: MEDLINE, EMBASE, EconLit, Pubmed, National Health Sciences Economic Evaluation Database (health economics literature) Web of Science (IT literature) Searched in October 2015 (from inception) No limits by year, language or human studies Reference lists of included articles reviewed
AND Search Strategy ECONOMIC DISCHARGE ELECTRONIC Economic Models Economic Evaluations Economic Analysis Cost-effectiveness Cost-utility Cost-benefit Quality Adjusted Life Years Financial Analysis Return on Investment Value Proposition Business care Markov Chains Discharge Summary Discharge Communication Patient Discharge Transition Web based Electronic Computerized OR
Inclusion/Exclusion Criteria INCLUSION Economic analysis (including RCT, modelling, and simulation) or cost analysis Electronic discharge communication used as intervention Reports on economic evaluation outcomes and/or costs EXCLUSION Non-economic analysis Non-electronic communication used as intervention Economic evaluation of other health records (not discharge) Does not report on traditional economic outcomes Published journal articles Published abstracts
Methods Abstract Review: Reviewed independently and in duplicate by two reviewers Kappa score calculated to measure agreement Full Text Review: Reviewed independently and in duplicate by two reviewers Kappa score calculated to measure agreement Data Extraction and Quality Assessment Conducted independently and in duplicate
Data Extraction and Analysis Extraction Variables: Referred to CADTH Health Economics Guidelines 2006 Analysis: o Year, country, population, outcomes, intervention, comparator, etc. o Economic specific variables: model details (time horizon, discount rate), currency, etc. Descriptive component-based approach
Results: PRISMA Flow Chart Number of records screened: 1000 Number of full texts assessed for eligibility: 57 Studies identified from references: 3 Number of studies included in synthesis: 4 Kappa = 1.000 Number of records excluded: 943 Kappa = 0.277 Number of full texts excluded: 53 Abstract or poster presentation only: 7 Not economic evaluation: 6 Not discharge intervention: 12 Discharge intervention, not summary: 23 Intervention not electronic: 3 Duplicate: 1 Study not found: 1 Number of studies excluded from reference search: 3 Not discharge intervention: 3
Author Year Country Methodological Approach Population Intervention Comparator Kopach, R., et al, Int J Technol Assess (7) 2005 Canada Cost-effectiveness Automation of medical documentation for entire hospital discharge Speech recognition technology signatures generated electronically, final documents sent through email or e-fax Dictation through telephone used to created voice file to be transcribed paper based signatures and traditional mailing Colsman, A., et al, Der Hautarzt (8) 2009 Germany Cost-analysis Dermatology department including 4 physicians and 3 typists Electronic medical record system combining laboratory, experimental findings, nursing performance indicators separate text editor used for writing discharge letters Typists used to create discharge document Aanesen, M., et al, Int J Med Inform (9) 2010 Norway Cost-benefit 10 hospital departments and 9 primary care physicians Discharge summary created electronically and sent electronically Paper based discharge Mourad, M., et al, J Hosp Med (10) 2011 Cost-analysis 600 bed quaternary care academic institution Note Writer with both free-text and autopopulated fields. Separate software tracks signatures and automatically triggers dissemination Orally dictated discharge notes
Author Title and abstract ( /2) Introduction ( /1) Methods ( /14) Results ( /4) Discussion ( /1) Other ( /2) Total ( /24) Mourad, M., et al (2011) 1 1 7 0 1 1 11 (10) Colsman, A., et al (2009) 2 1 7 1 1 0 12 (8) Aanesen, M., et al (2010) 2 1 8 2 1 0 14 (9) Kopach, R., et al (2005) (7) 2 1 11 2 1 1 18 CHEERS Score (11): Methods: Measurement of effectiveness, Measurement of valuation of preference based outcomes, choice of model, assumptions Results: Study parameters, characterizing uncertainty, characterizing heterogeneity
Kopach, R., et al (2005) (7) Primary Objective Primary Outcome Conclusions Compare traditional system with dictation tool ICER of $0.331 (in 2003 CDN $). Spending an additional $0.331 per discharge, average time of note completion decreased by one day. Automated documentation system costs more, but reduces document completion time. Colsman, A., et al (2009) (8) Determine the extent to which a hospital information system for patient data supports the creation of a discharge report Total cost per page per discharge letter in the comparator is 10.71. Total cost per page per letter in the intervention is 9.51. Intervention is advantageous to typists but not physicians Aanesen, M., et al (2010) (9) Examine consequences of delayed implementation Dynamic Net Present Value (DNPV) for 5 year implementation of electronic message exchange in hospitals and primary care units is 31.1 million. Greater DNPV for faster implementation of electronic discharge tools Mourad, M., et al (2011) (10) Business case for electronic discharge communication tool Yearly costs of discharge using current system is $496,400 (USD). Cost of a 14 day delay in billing is $107,000-$215,000 (USD). Investing in e-discharge has real-time benefits
Results: Mourad et al Presented business case for EDCTs Identified list of costs to consider prior to tool adoption Infrastructure Personnel Maintenance Modified to include time variable
Infrastructure + N/A Software/Licensing + N/A Network connectivity Server capacity for backup system Interface with current electronic medical records Kopach, R., et al (7) Colsman, A., et al (8) Aanesen, M., et al (9) Mourad, M., et al (10) Intervention Control Intervention Control Intervention Control Intervention Control Hardware + N/A Personnel Physician champion Physician training Computer programmer Transcription + + + + + Deficiency tracking Notification N/A + Postage/Dissemination + + Maintenance + + Computer/printer maintenance Network maintenance Software add-ons and updates Time savings + + + + + + Time delays + + +
Conclusions We identified 4 studies All were heterogeneous with respect to outcomes, methods and quality assessment Most focused on time savings as the outcome (ICER = $0.331, Cost per page per letter, Adoption delay, Billing delay) Inconsistencies in how time savings was measured None of the studies measured meaningful health related patient quality or safety outcomes Cost-effectiveness of electronic discharge tools not often reported When reported: poor quality, important costs excluded
Limitations Publication bias: We may have missed business cases written for electronic discharge tools in health care o These may not be published or available to the public Relevance of evidence: The most recent study was Mourad et al 2011 Kopach et al 2005 identified that their system would be irrelevant in 3 years Transferability/Generalizability: Estimates are heterogeneous and quality of evidence is weak
Discussion Infrastructure and maintenance costs not considered Patient safety and quality measures excluded Understanding of cost-effectiveness of these tools is limited
Future Work Focus on traditional economic evaluation outcomes Cost-effectiveness Cost-utility Capture costs identified as essential for adoption RCT of effectiveness with economic evaluation and clinical measures Death Readmission Health Related Quality of Life
Acknowledgements Funding sources: Supervisor: Dr. Fiona Clement Co-authors: Rosmin Esmail, Karen Tang, Diane Lorenzetti, Paul Ronskley, Matt James, Maria Santana, William Ghali Contact: lsevick@ucalgary.ca